Page 1474 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 105: Gastrointestinal Hemorrhage 1013

A placement because inadvertent inflation of the balloon in the esopha-
gus can lead to esophageal perforation. Once adequate positioning
is ensured, the gastric balloon can be inflated fully according to the
manufacturer’s recommendations (gastric balloons are inflated to
predetermined volumes, whereas the esophageal balloon component
is inflated according to pressure). If hemostasis is not achieved by
isolated inflation of the gastric balloon, the esophageal balloon can be
inflated to 35 mm Hg, a pressure exceeding the intravariceal pressure.
Following inflation, traction should be applied to the apparatus at
the insertion site to maintain proper positioning. A maximum dura-
tion of 48 hours is recommended for variceal compression because
Varix prolonged tamponade can lead to esophageal wall ischemia. A naso-
gastric tube inserted above the esophageal balloon is mandatory to
prevent aspiration of oropharyngeal secretions that collect above the
inflated apparatus (eg, Sengstaken-Blakemore tube), unless the tube
Lumen
has its own lumen for esophageal suction (eg, Minnesota tube). A
major limitation of tamponade therapy is the high risk of rebleeding
following deflation of the balloon. Furthermore, given the serious
complications of pulmonary aspiration and esophageal ulceration
and perforation, this mode of therapy should be performed by skilled
personnel and generally as a temporizing step while planning defini-
B tive treatment such as a TIPS. For gastric varices, balloon tamponade
should be attempted using the Linton-Nachlas tube which has a
600-mL volume single gastric balloon that seems to be more effective
in controlling fundal variceal bleeding. 47
Transjugular Intrahepatic Portosystemic Shunt: Following temporary stabi-
lization with balloon tamponade, further definitive treatment to achieve
hemostasis involves the creation of an artificial vascular shunt between
the systemic and portal circulation in order to decompress the variceal
vasculature. This can be accomplished surgically (discussed below) or via
TIPS, which offers a less invasive method for obtaining a vascular shunt.
The TIPS consists of an expandable metallic stent placed intrahepatically
between portal and hepatic veins using radiologically guided access.
Rubber band Traditionally, TIPS has been recommended as secondary prophylactic
therapy for variceal bleeding in the setting of mild to moderate liver
disease, and advanced cirrhosis has been regarded as a contraindication
Varix to TIPS therapy due to increased mortality after TIPS in this setting.
However, recent studies with favorable hemostasis and mortality data
Edge have supported the use of emergent TIPS as salvage therapy for refractory
of ligator variceal hemorrhage, even in advanced cirrhosis. 48,49 Therefore, when vari-
ceal hemorrhage is refractory to pharmacologic and endoscopic therapy,
FIGURE 105-2. A. Esophageal varix before banding. B. Variceal banding viewed urgent TIPS therapy should be considered irrespective of the severity of
through endoscope. hepatic disease. The hemodynamic benefits of TIPS therapy can be attrib-
uted not only to portal decompression and variceal hemostasis, but also to
away from the venous system of the gastroesophageal junction to increased venous return due to intravascular mobilization of any existing
that of the gastric mucosa. Bleeding from PHG is characterized by a ascites. Additional beneficial effects of TIPS therapy include treatment of
diffuse, slow bleed from the gastric mucosa that typically is not refractory ascites and the hepatorenal syndrome.
amenable to localized endoscopic therapy. Recently, early TIPS has been investigated to prevent variceal rebleed-
■ SALVAGE THERAPY FOR ENDOSCOPICALLY UNCONTROLLED BLEEDING ing and improve outcome early after EBL therapy in patients with
Child-Pugh class C or those in class B who have persistent bleeding
50
In the event that hemostasis cannot be achieved by initial endoscopic at endoscopy. Early TIPS (within 72 hours of admission) was com-
therapy or there is evidence of rebleeding after initial hemostasis, a pared with standard therapy (continuation of vasoactive drug therapy),
repeat trial of endoscopic therapy may be attempted. However, following followed after 3 to 5 days by treatment with propranolol or nadolol and
a second failed endoscopic trial, nonendoscopic interventions need to long-term EBL. Patients in the standard therapy group received TIPS
be implemented emergently. These interventions may include balloon if needed as rescue therapy. The early TIPS group was more likely to
tamponade, TIPS, and surgical therapy. remain free of rebleeding events compared to the standard therapy
group (97% vs 50%; p < 0.001). The 1-year survival was higher in the
Balloon Tamponade: Tamponade tubes (such as the Sengstaken- early TIPS group compared to the standard therapy group (86% vs 61%;
Blakemore or Minnesota tubes) effectively achieve short-term hemo- p < 0.001). In light of the findings in this study, early TIPS could be
50
stasis by compressing the gastric and distal esophageal mucosa. In considered in patients with advanced cirrhosis at high risk of variceal
most cases, tamponade is effective after inflating only the gastric rebleeding; however, larger multicenter trials are needed to validate this
balloon. Endotracheal intubation is imperative prior to insertion of study’s findings.
tamponade tubes to decrease the risk of aspiration. Once the airway is
secured, the tube can be passed either nasally or orally to the stomach. Surgical Therapy: Since the advent of TIPS as salvage therapy for refrac-
The gastric balloon should be inflated only partially (with approxi- tory variceal hemorrhage, there has been a reduction in the need for
mately 30 mL of air) pending radiographic confirmation of correct surgical intervention. However, shunt surgery for portal decompression

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